Insurance commissioners eye Cigna following report of physicians denying claims without reading them

State insurance commissioners and federal lawmakers are raising concerns with Cigna's internal claims review process following reporting from ProPublica in March that said the payer denies large batches of claims without reviewing them first.

Many states require medical directors to review patient files and coverage policies before denying claims for medical reasons. ProPublica alleges that Cigna has bypassed these steps by having a computer algorithm complete the review and then having physicians sign off on groups of denied claims.

"It's hard to imagine that spending only seconds to review medical records complies with the California law," Dave Jones, California's former insurance commissioner, told ProPublica. "At a minimum, I believe it warrants an investigation."

"I'm afraid it might be the tip of the iceberg," Washington's insurance commissioner, Mike Kreidler, told the publication. "We darn well better start paying attention to it."

"Given your article, this will likely warrant a closer look," a spokesperson for Delaware's insurance department told ProPublica.

"This is very concerning," an anonymous Labor Department official told ProPublica. "I don't see a scenario where we’re not taking a hard look at these kinds of practices."

On May 16, Rep. Cathy McMorris Rodgers of Washington and chair of the House Committee on Energy and Commerce, said that Cigna's Medicare Advantage members appeal 20 percent of denied claims, and about 80 percent of those denials are overturned.

"If these figures are at all illustrative of Cigna's commercial appeal and reversal rates, it would suggest that the PXDX review process is leading to policyholders paying out of pocket for medical care that should be covered under their health insurance contract," Ms. Rodgers said in a letter to Cigna.

Not all claims go through the specified review system, PxDx, and it is not clear how many are approved or sent to physicians for review, the original report said. The review system was instituted more than a decade ago and other payers have used similar processes.

On May 16, a Cigna spokesperson told Becker's it welcomes "the opportunity to fully explain our PxDx process to regulators and correct the many mischaracterizations and misleading perceptions ProPublica's article created."

"We categorically disagree with this mischaracterization of our process for accelerating payment of claims for routine, low-cost screenings," a Cigna Healthcare spokesperson previously told Becker's. "PxDx allows us to automatically pay providers for claims that are submitted with the correct diagnosis codes, and prioritizes our medical directors' time for more complex reviews. It does not create any impediments to or denials of care because it takes place after a patient receives the service, and even a denial does not result in any additional out of pocket costs for patients using in-network providers."

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